Most Common Mistakes in Step 2 CK Prep

*Note: I first wrote this article about the USMLE Step 2 CK around 5 years ago way back in March, 2010. It is one of my more popular posts with over 80,000 page views. Since that time, I have had many students who have passed Step 2CK with very good scores and went on to finish their residency training. Throughout the past five years, the 4 points listed in this article have remained the most common mistakes student make in prepping for the USMLE Step 2 CK.

The USMLE Step 2 CK is a relatively easier exam than the USMLE Step 1 and yet a lot of people still fail or do poorly because of mistakes in their prep. For the past 5 years, since I originally wrote this article, I have had many students who have passed Step 2 CK with very good scores and went on to finish their residency. I have compiled the most common mistakes I have found in their prep that we had to correct before they went on to pass Step 2 CK.

First, Not Studying Enough Detail.

The purpose of the USMLE Step 2 CK is to test your readiness to apply clinical science in medical practice and you need to know a lot of medical facts in order to do that. IT is not an OPEN BOOK test, so you need those facts in your head. And yet too many people make the mistake of studying only very little.

The fact that you see so many popular reviewers in the market that purport you can ace the exam by studying the little material it contains reinforces this serious misconception. That is a lot of bull. Medicine is a very broad subject and Step 2 CK covers all the most common and even some rare cases. Those little reviewer just does not give you enough detail to do well in this exam.

The problem with those mini-reviewers is that they presume you have just finished or are in the middle of your clinical rotation when you will sit for Step 2 CK. They also presume you did a lot of deep reading during those clinical rotations, which any medical student know is almost impossible unless you decide that you do not need to sleep.

Do yourself a favor and actually read and study for the USMLE Step 2 CK in detail. In most cases using Kaplan Notes supplemented by Step-Up to Medicine is good enough to get a decent score although you need to do more if you want to score high. For old IMG, you may need to supplement your reading with more detail, especially for IM and Ob-gyne.

I will post a more detailed discussions on the different books and review materials you need to use depending on your particular circumstances (fresh grad, Old IMG, third year, etc.) in future posts. If you want to be notified of future update and posts, sign up for our free email notifications.

Second, Not Preparing for Next Best Step in Management Type of Questions

Next best step in management type of questions account for about 20% of Step 2 CK. This type of questions involve cases that describes the management done on the patient so far and asks what you think is the next best step in dealing with this particular patient.

Normally, when we read clinical science books we are taught how to diagnose and treat patient. But in clinical practice, we need to work up patients, not just diagnose them and we need to manage patients, not just treat them

Diagnosing a patient requires knowledge of signs and symptoms and what examinations and test to be done to elicit these signs and symptoms. Working up a patient involves knowing implications of positive and negative results of previous tests and physical examinations and what lab or diagnostic test should be ordered next as well as further diagnostic maneuvers that needs to be performed.

Treating a patient involves knowing what drugs and treatments to use. Managing a patient takes into consideration patient response, adverse reactions and other factors and altering the treatment accordingly.

Most people study for Step 2 CK by reading textbooks and reviewers. That is of course the appropriate way to study the clinical content for the Step 2 CK exam. However, most textbooks present diagnosis and management combined with detailed discussion of pathophysiology and other clinical details. This tends to obscure what is the next best step in your head. Come exam time, you will spend valuable time trying to remember the exact step by step by recalling all the other details when you just need the next best step.

For example, you have a case of a patient who came in with chest pain and you suspect it to be a case of Acute Myocardial Infarction. In a next best step questions, all 5 choices are correct choices in the diagnosis and management of AMI but you need to decide which of the five is the next best step. Give streptokinase, hook up to a cardiac monitor, extract blood for cardiac enzymes, give nitrates, etc. Unless you know the exact step-by step diagnosis and management of Acute MI, you will be lost as to the best answer.

The best way to study next best step in management type of question is to construct algorithms that outline the diagnostic and management steps you need to take for any particular type of clinical situation. You can answer the next best step in management type of question without using algorithms but it will take longer and more analysis to be able to answer them. And as we all know, in the USMLE time is what you lack.

I will write more on how to write algorithms in a future post. I will also recommend some books that contain diagnostic and management algorithms. If you want to be notified of future update and posts, sign up for our free email notifications.

Third, Knowing too little Pathophysiology or Mechanisms of Diseases.

Pathophysiology, better known as mechanisms of disease in Step 2 CK comprises about 20% of Step 2 CK. That is the biggest reason why I emphasize studying pathology and pathophysiology really well when prepping for Step 1 as it is not only the biggest subject in Step 1, it covers significant portions of Step 2 CK and Step 3.

While Step 1 primarily covers General Pathology, Step 2 CK covers primarily Systems Pathology. Also in Step 2 CK, the pathophysiology tested are more clinical in nature, i.e. how they account for various signs and symptoms and complications of diseases. You will also encounter cases which I call “applied pathophysiology”. If you did algorithms for diagnostic workups and patient management, you may know the next best step in management, but applied pathophysiology helps explain the reason why. Why this test, not that. Why they may look the same but actually are not. I will write about applied pathophysiology in more detail in a future post. You may want to subscribe to our email updates so you know when it’s posted.

This is usually a problem for old IMG’s who decide to take Step 2 CK first instead of Step 1. If you really have to take Step 2 CK first, then make sure to cover this well. Even if you took Step 1 first, this becomes a problem if you did not study pathology we and did poorly.

The solution is therefore to make sure that you are solid in pathophysiology. Goljan’s Rapid Review for Pathology is a short but good book to brush up on pathophysiology, although it covers general pathology as well which is not needed in Step 2 CK. Reading Harrison’s Principles of Internal Medicine or Cecil’s Textbook of Medicine also covers the topic pretty well.

Fourth, Failure to Recognize Atypical Presentation of Common Diseases.

According to Cecil’s Textbook of Medicine, there are four types of cases you normally encounter in clinical practice. In order of frequency, they are (1) common diseases with typical presentation, (2) common diseases with atypical presentation, (3) rare disease with typical presentation and (4) rare diseases with atypical presentation. They also occur roughly in the same number in Step 2 CK with slightly more type 2 cases than normal.

In Step 1, most of the cases you will encounter are presented classically. But in real life you rarely see classical cases where all the key signs and symptoms are present. Even in Type 1 cases, not all the signs and symptoms will be there. However, enough will be present so diagnosis is not so difficult.

The big problem in Step 2 CK for most people is type 2 cases where common diseases presents atypically. For example, although sarcoidosis is most common in young, black female. They do occur in males, older people and other races. So in Step 2CK a sarcoidosis patient may be an old, white male instead. You need to be able to diagnoses the case even with atypical presentation or you won’t be able to answer the questions. This is usually a problem with medical students with limited clinical experience and old grads who have not practiced medicine for some time.

Other ways clinical cases are tougher in Step 2 CK is the addition of both relevant and irrelevant normal findings and the addition of irrelevant abnormal findings that will not change the diagnosis. You need to be able to discern what facts are important and what are not. Remember in an actual live patient, they may present with symptoms that is irrelevant to their main complaint and you need to decide what is relevant and what is not.

The best way to correct this problem is to study classical cases and know what symptoms and signs are absolutely essential in making a diagnosis. When doing qbanks and you misdiagnose a case, it may make sense to find out where you got it wrong and write down the minimum symptoms and signs you need to make the diagnose, so you don’t make the same mistake again.

These 4 are the most common reason for getting low score. Although there are other less common weak points that can cause lower score, they will be discussed in another post. You may want to subscribe to our email updates so you know when it’s posted.

hi ask doc,
Is there any chance that you’ll also have a prep course for step 2 ck? I had written here earlier & I have failed both step 1 & ck.. Planning to take ck now as I had studied for it recently but now im confused which one to take.. which one will u suggest? plz advice..

I am trying to get a step 2 CK course running before the end of the year. I would suggest you take Step 1 first. The main reason is that 20% of Step 2 CK is pathophysiology and that is best studied during Step 1. If you proceed to Step 2 directly, you still have to study this pathophysiology.

Hi, i just found out I failed ck. I have 5 weeks to study and need advice on what sources to use. I was considering first aid for ck and uworld questions. I am a slow learner. If u have any advice, I would be very thankful.

hi askdoc…i have got 2008 edition of kaplan notes for ck …is it good enuf to start the preparation or shud i join in kaplan for new edition notes….and what about master the boards by fischer for ck????? many of my friends have started uworld directly without even studying kaplan notes….is it a good idea what is ur suggestion

It should be no problem. Kaplan notes does not really change much year to year or even 5 years. Master the boards by fischer is a good learning tool, will recommend it. Starting uworld without reading Kaplan may work for recent AMG grads but for most IMG it is a risky strategy. There are people who can make it work and pass, but understand not everyone could and they are in the minority. So chances are its too big a risk for you to do it that way. If you want a high score, than just using uworld directly is a no-no. Still recommend that you read Kaplan, make algorithms, then do Uworld.

My compliment dear doctor for this wonderful blog. I am preparing for usmle 2 ck and I read kaplan notes 3 times than first aid 2 than the book of conrad fischer and the usmle 2 made ridiocusly simple and a pass to step 2. Than I did the qustion books like usmle secrets, mock exam, lange 2, pre test.Than I saw thw kaplan videos and time Qbank on line. Is that enough about you? Thank you

My compliment dear doctor for this wonderful blog. I am preparing for usmle 2 ck and I read kaplan notes 3 times than first aid 2 than the book of conrad fischer and the usmle 2 made ridiocusly simple and a pass to step 2. Than I did the qustion books like usmle secrets, mock exam, lange 2, pre test.Than I saw thw kaplan videos and time Qbank on line. Is that enough about you? Thank you very much.

The study materials you are using are certainly enough to do well in the examination. But remember, studying the right things is just a small part of doing well in the exam. You need to study the right way to insure you can retain and recall what you have studied. Be able to interpret and analyze correctly the cases presented to you. And understand in detail how to manage the cases, diagnostically and therapeutically. So even if two people use the same materials but study differently, the results will differ.

Hey Askdoc.. i m not sure u remember me..
just to refresh yr memory.. i got a poor nbme correlation last september and was totally burnt out and didnt kno wht to do since exams were a few days away. I had a lot of pressure on me to finish it soon..instead I took yr advice and cancelled it..took a month’s break and started all over again. I finally finished it this march and scored 241/99. I am very thankful for providing me that kind of advice.. else i would have to settle with a poor score and never have a chance at a competitive program. Your advice to really master the subject and kno the ins and outs of it kind of stayed with me and tht’s exactly what i did whn i restarted my prep.
I took my CS within 2 weeks of my step 1 and passed that too..
I m onto CK now and i have my exam scheduled in 1st week of october..
My main resources are UW, MTB-ck and i keep looking into CMDT if i need more information.
I intend to take a self assessment exam soon and i would appreciate your recommendation between UWSA and NBME.. please let me kno which order i should take the tests and which exam has the highest correlation. Also, i d appreciate if u could let me know how helpful MTB-3 is?
Your blogs have been very helpful..and i want to take this opportunity to Thank you for giving me sound advice when i needed it most.
Bella

Have not really used MTB for Step 2 CK. Would still recommend Kaplan Notes. CMDT is very helpful in understanding diagnostic steps and therapy. You still need to use NBME for step 2 CK more than UWSA. Would be best if you can tell me your current average in qbank.

i have just graduated and doing my clinical rotation in the hospital. i recently gave PLAB 1 which was all about clinical knowledge ,and i’m planing to give step 2 ck next within a few months .i hav’nt given step 1 as yet pls guide me if i should give step 2 ck before step 1.

Hi , I’m an old IMG’s, I live in Canada , and I have the opportunity to pass ( for the second time ) the USMLE step 2 CK , in a short time period ( 3 months ), using the Kaplan lecture notes 2008 , is it enough ? and comparing to the canadien EECMC exam , which one would you advise me ?
Thank you very much

Good afternoon wherever you are Mr. Askdoc. I am an IMG who passed step 1 last year with a 226/82 (under the new scoring system.)

I am now preparing to study for step 2 which I will be taking in exactly 12 months from now. I know this is a long time, but how would you suggest preparing for someone in my situation? Perhaps I can give you a bit more background so you can understand how my situation is slightly unique…

I finished step 1 in November with a VERY good understanding of pathophys…. perhaps my strongest subject. I used Goljan RR w/ audio to prepare and this got me in a great place for the step 1. I then however had to take 5 months off before I could start rotations because well… I went to a bad Caribbean school and they gave me the run-around for a while before they actually scheduled me for rotations.

Now I have finally started and I find that I have forgot A TON!!!!!!! of pathophys and pharmacology.

Currently I am trying to decide if I should be reading Goljan RR again during my clinical rotations to prepare for step 2. I also plan on using Kaplan Videos, the Conrad Fisher book, and FA Step 2.

Hoping you could give me some advice, because in reading your other posts you seem VERY knowledgeable on the subject!

Goljan RR is good for Step 1 but is not really recommended for Step 2CK. Kaplan videos is good only for understanding concepts. You can’t memorize videos. Conrad Fisher book is for high yield review, which is really the last step in the review process. You need to make sure you cover all the materials first. Or you will go to the exam feeling all the questions are familiar but somehow you can’t answer them. Same with First Aid. You will be committing the error of not studying enough details. Probably reading Kaplan Notes, add Step Up Medicine then either conrad Fisher book or FA. Dont really need both. Then Q banks. Even Fisher’s book is not complete in terms of topic. Either supplement with Washington Manual of CMDT.

Hello Sir,
I’m an intern from India. Finished mt final year dis February. I would like to pursue M.D Internal Medicine and specialize in oncology in the US. I have 2 questions
1. The 1 question that may probably irritate U – Should I take up step 2 first?
2. People here advice me to read Books, and not notes, is it even feasible?

There really is no hard and fast rule that you cannot take step 2 first. Except it is more advantageous to take Step 1 first overall. But if you have a good reason why Step 2 first (aside from the claim that since you just finished your clinics, take step 2 CK first is easier) then its better to take Step 1 first for the reasons I have cited in one of my posts.

As to the second question, if you lack understanding of the main topics tested, you need to read books to understand them, not notes. However, come time to memorize details, you need to read notes. because notes present the same information from textbooks in more compact form. Compact info means easier to memorize, retain and recall for the exam. For example, which is easier memorizing a five page discussion of the coagulation cascade or a one page illustration. In reality it is easier and faster to memorize and recall the illustration, but unless you understand coagulation cascade, you can’t make heads or tails of the illustration unless you read the 5 page discussion. Books for understanding, notes for memorization.

All that is explained in my book, How to Master the USMLE Step 1. So I suggest you go to Amazon to buy it and read it. Even if you are studying for Step 2 CK. the study methods are the same except all my examples from the book are for Step 1. For Step 2, you use the same study methods except for one addition. Algorithms for diagnostic workup and treatment protocols, which is important in Step 2 and Step 3. Otherwise all other study methods are the same.

Let me give you my context. I’m doing my finak year of kedical school in the US at a hospital; doing rotations to gain clinical experience and letters of recommendation. I took step 1 on dec. 2009, scoring 219. I’m planning to do pediatrics at a children’s hospital. I still have one year of social service doing research before I can get my degree as an US IMG.

Lately I’ve gotten the feeiling of taking step.2 ck this dec. But I’m not sure if I would be able to prepare myself enough with ksplan notes, videos and usmleworld, in the midst of rotations, or if I should wait until next year, when I’ll be free after 2pm every weekday to study. Should I concentrsge in my rotations and lesve step 2 study for later? If I were to ask for a full month off tjis year, would that be long enough to prepsre myself adequately? I plan to apply for the 2014 match.

Actually depends on how high a score you are aiming for. 4th year medical students could probably do with 2 months full time prep so long as they are doing well in medical school. Longer if you plan to ace it. I would say, start reviewing now, track your progress so you can make an estimate of how long you can be prepared, then schedule your exam.

Thank you for providing so much useful info! I was wondering if you are familiar with the Toronto Notes and have any thoughts on using them for Step 2 CK prep? I find them very useful to keep up with classes (I study in Hungary) and I’d like to continue and use them for Step 2. However I haven’t found much info from anyone who has used them as a main resource for USMLE prep. Any advice?

Hi Ask doc,
I am an IMG from India. I hae read the textbooks well during my rotations that includes the harrison’s, nelson’s, schwartz and williams and prepared notes of my own am quite sure I know the contents well. I wanted to know if I was ready and took the usmleworld question bank. I could answer more than 85% qs from internal medicine and pediatrics but things are not going great with surgery. I have not done psych and obg yet. Please tell me what i should do

What will determine your chances for residency is the following in order of importance. 1 Your Step 2 CK score and Step 3 (you probably need at least 90’s to have a chance), 2. Your visa status (if you don’t need visa, you have a good chance, otherwise not too good) 3. The hospitals you apply to. Anyway, it will be hard but not impossible.

hi i have been preparing for this exam since 4 months but seriously for 2 months plan to give exam next month . i did u world 1st time with average of 68% . i just want to know is this ok score for u world and how can i improve it ,i did kaplan 2 times long ago, but now i am using more mtb2 for IM and and rest of subjects i am using mtb 2 and 3 . tell me how can i improve my score in exam and how can i get better score in exam . i have plan to give u world assessment in 15 days \

Hi Ask doc,
I have a problem that has been bothering me for a long time now. I was evaluating my UW qbank for step2 ck and I found out that majority of questions that I got wrong are the ones answered by most people(60-80%) while many questions that most got wrong are answered by me(30-40%) .I don’t know where I am going wrong. I know I can ace the exam but for that I need to have a good hold over common questions. Please suggest me where am I going wrong and what should I do about it.
Thank you,

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